Intensive Care Network Podcasts

Matt Anstey is an intensivist from Sir Charles Gardener hospital in Perth, Australia. He gave this talk on outcomes after intensive care at an ICN WA meeting in Perth last year.

Shree Basu and Lily Foster are paediatric intensive care trainees. They give an introductory podcast to paediatric cardiac intensive care, covering recognition of congenital heart disease, early and emergency pre-operative management principles, and classification of the most common lesions.

You can’t treat pancreatitis without antibiotics by Dr Emma Goeman

A quick interview with Mark & Lee from Developing Emergency Medicine giving some information about the 2018 Developing Emergency Medicine conference in Fiji. The conference will be held ath the InterContinental Fiji Golf Resort & Spa on Nataola Bay, from Monday 3rd December - Thursday 6th December 2018, with the two day ultrasound workshop the weekend prior.

Liver disease in ICU – when to stop? by Professor Julia Wendon

Hepatic resections are complex surgical procedures harboring a significant risk for complications. In line with the continued development of liver surgery, hepatic resections tend to be more complex and extensive, with to this associated enhanced risk for post-hepatectomy liver failure (PHLF). Despite these improvements in outcome after major liver resection, PHLF remains one of the most serious and fatal complication of major liver resection occurring in up to 8 % of the cases. Multiple factors increase the risk of PHLF but in clinical practice the risk of PHLF is closely associated with the assessment of the pre-operative Future Liver Remnant (FLR). Accordingly the prevention of PHLF is alleged to be affected by the induction of hypertrophy of the liver remnant via portal vein embolization or ligation if the expected functional left remnant in cases where the FLR is judged too small. An alternative therapeutic strategy is to perform a two-stage procedure allowing the FLR to grow after the first non-curativ

Management of the patient with decompensated liver disease is clearly more straightforward in specialist centres with multi-disciplinary input, access to liver transplantation teams and advanced technology. Bioartificial extra-corporeal liver support systems are undergoing evaluation and include the extra-corporeal liver assist device (ELAD developed by Vital Technologies). ELAD is an investigational, extra-corporeal, human cell-based system. The human liver-derived cells (VTL C3A) may mimic certain functions of in vivo human liver cells. The principles of operation of the ELAD system are as follows: plasma ultrafiltrate is passed through hollow fibre cartridges containing human liver-derived cells (VTL C3A cells) and allowing two-way transfer of toxins, metabolites and nutrients, mimicking liver function. Toxins, such as bilirubin, glucose and oxygen pass from the ultrafiltrate to the VTL C3A cells. Treated plasma ultrafiltrate is then reconstituted with blood cells and returned to the patient. Data evalua

The patient with chronic liver disease presents a range of potential challenges when a severe intercurrent illness occurs or major surgery is required. Even well-compensated liver cirrhosis in high functioning patients renders such individuals vulnerable to a myriad of problems when physiological stressors occur. Severe acute liver failure is another clearly defined sydrome in which extremely rapid and complex multiple organ failure typically ensues. Whilst intensivists are familiar and adept with the management of other major organ failure, new acute liver failure or decompensated chronic liver disease is particularly difficult to manage due to the inherent breadth of roles that the liver has in maintaining health as well as the current lack of comprehensive support therapies other than organ transplantation. While effective artificial life-supports for severe respiratory, cardiac or renal failure are available in the intensive care setting, support for over liver failure is less straightforward. The failin

Despite the publication of a number of studies over recent years looking at energy delivery and outcomes in the critically ill population we remain uncertain how best to determine optimal calorie delivery for our patients. The concept that energy delivery should match energy consumption is plausible and intellectually attractive bu Broadly speaking clinicians can be divided into 3 categories according to their approach on energy delivery to the critically ill. Some believe that optimal clinical outcomes are achieved by closely approximating energy consumption i.e. providing full calorie requirement, usually around 2000kcal/d for the standard sized adult. This position is supported by a number of observational studies, however, patients usually only receive about 60% of what they are prescribed. Some believe that attempting to provide full feeding exposes the patient to the risk of overfeeding and that ‘permissive’ underfeeding is safe and better tolerated in critically ill patients where gastrointestinal fun

by Professor Jas Samra

The 105 years since the first successful thoracic oesophagectomy was performed saw initially slow progress in terms of operative mortality, morbidity and oncological outcomes. Even until the late 1990’s, operative mortality figures of 15-20% were commonplace and long term survival was poor, as low as 12%1. The last 20 years has seen a major change in these outcomes both within Australia and overseas. These improvements have been based on the bed rocks of improved surgical techniques, improved peri operative care, changes in the distribution of the pathophysiology of the disease, improved patient selection through better staging, Development of endoscopic techniques for early tumours, development of effective neo adjuvant regimes and the development of “high” volume centres have all contributed to the current figures of 4% preoperative mortality and overall 5 year survivals in the post surgical patient of 40%. Better understanding of the nutritional issues involved has led to an emphasis on better quality of

Role of endoscopy in upper GI bleeds by Professor Michael Bourke

According to a quote variably attributed to Niels Bohr, Yogi Berra, Albert Einstein, Mark Twain and others ‘prediction is difficult; especially about the future’. Nevertheless, in an era of evidence-based medicine, one might surmise that the future of management of GI bleeding in the ICU will be informed by large-scale high quality RCTs. There are a number of such trials on the horizon that give us a pretty good idea of what the future holds. Based on my best-guess of what these trials will show I predict that in the future we will: 1. Use more TXA in patients with GI bleeding. 2. Use less stress ulcer prophylaxis. The Haemorrhage ALleviation with Tranexamic acid (TXA) – InTestinal system trial (HALT-IT) is a pragmatic trial that will compare TXA to placebo in 8000 participants with clinically significant gastrointestinal bleeding. The rationale for this trial is that decreasing fibrinolysis with TXA will increase clot stability, improve haemostasis, and reduce rebleeding, leading to reduced mortality for p

Peptic ulcer bleeding (PUB) carries a 10% risk of death within 30 days and accounts for 36–46% of emergency upper gastrointestinal bleedings (UGIBs). The annual incidence of hospitalization due to PUB is 19–57 per 100,000 persons. Most of these patients undergo esophago-gastro-duodenoscopy (EGD), estimated to 2000 patients in Denmark alone every year. The poor prognosis in PUB is partly due to the clinical condition itself, and partly due to the high prevalence of medical comorbidities. Hence, optimizing pre-, intra-, and post-endoscopic patient management are likely to be important in order to minimize the risk of death and improve outcome. Although duodenal ulcer (DU) and gastric ulcer (GU) seem to be identical diseases with a considerable overlap in both risk-factor profile and clinical manifestations, ulcer site could potentially affect outcome. However, the prognostic importance of ulcer site has not been extensively evaluated, and existing knowledge is ambiguous. Two systematic reviews of predictors of

At this year's CICM ASM in Hobart, Tasmania, there will be the second CICM trainee symposium. This is a day of lectures and discussions targeted specifically at CICM ICU trainees and immediately precedes the CICM ASM meeting itself. More details are here.

Acute liver failure - what tomorrow might bring? by Professor Julia Wendon

Because of widespread recognition that surgical quality varies widely, there is growing demand from patients, providers, and payers for better measures of surgical outcomes. Risk-adjusted mortality rates are a simple and reliable measure of surgical quality and have been used to good effect in cardiac surgery. One way to improve outcomes measurement in non-cardiac surgery is to combine several operations together when assessing hospital mortality rates. While previous studies show relatively weak relationships between outcomes for different medical diagnoses, there is some reason to believe these relationships may be stronger in surgery. Many high-risk operations are dependent on the same hospital-level resources, staffing, and processes of care. Findings suggest that procedure-specific mortality is strongly related to a hospital’s mortality with other operations. In some cases, mortality with other operations is a better predictor than other proxy measures of quality, including hospital volume. The main res

That the gastrointestinal tract exerts an important, but unseen role in the pathogenesis of human disease has been a recurring theme over recorded human history. The Egyptians believed that a factor from the gut known as “ukhedu”, or “something disgusting”, was a factor in disease. At the turn of the century, and based on the ideas of Elie Metchnikoff, the gut was held responsible for the process of aging, and multiple innovative approaches were tried to arrest the passage of time. Following World War II, the gut was proposed to contain a factor (later shown to be endotoxin) that contributed to the hemodynamic arrangements of shock, and 30 years ago, we and others proposed that the gut was the motor of multiple organ failure. Today the focus of studies of the gut in critical illness is on the microbiome, and the way in which illness alters it. Each of these paradigms has generated new pathologic and therapeutic insights. The human GI tract contains a remarkable number and diversity of microorganisms in intim

Resilience and Sustainable Work Practices by Dr Bronwyn Avard